STRATEGIES FOR PREVENTING AND MANAGING
FALLS ACROSS THE LIFE-COURSE
Step safely:
strategies for preventing and
managing falls across the life-course
Step safely: strategies for preventing and managing falls across the life-course
ISBN 978-92-4-002191-4 (electronic version) ISBN 978-92-4-002192-1 (print version)
© World Health Organization 2021
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CONTENTS
FOREWORD vii
List of contributors
viii
Acknowledgements
viii
Abbreviations and acronyms
ix
CONTENTS
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE Iv
SECTION 1 15
THE MAGNITUDE OF FALLS WORLDWIDE
Why are falls a growing problem?
18
What are the risks?
19
Approaches to preventing and managing falls
38
Who is most at risk?
20
Children and adolescents
20
Workers
25
Older people
31
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE iv
39 SECTION 2
ASSESSING THE FALLS SITUATION – KEY STEPS
INTRODUCTION 01
Who is this technical package for?
04
How this technical package was developed
06
What this technical package contains and how to use it
10
A systems approach to addressing falls
11
Falls: key facts
14
47 SECTION 3
Interventions to prevent falls among children and adolescents
51
Interventions to prevent falls among workers
73 INTERVENTIONS FOR PREVENTING FALLS ACROSS THE LIFE-COURSE
87
Interventions to prevent falls among older people
125 SECTION 4
Injury management systems
128
Post-fall care and targeted secondary prevention
144
Pre-hospital care
132
Hospital care
135
Rehabilitation
139
MANAGING FALLS
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE vI
147 CONCLUSION
RECOMMENDATIONS 151
REFERENCES 160
ANNEX 1: SAMPLE SITUATIONAL ASSESSMENT FOR REDUCING FALLS AMONG CHILDREN
155 ANNEX 2: NATIONAL HEALTH AND MEDICAL
RESEARCH COUNCIL OF AUSTRALIA “BODY OF EVIDENCE MATRIX”
159
PHOTOGRAPHY CREDITS 181
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE vi
FOREWORD
The vast majority (82%) of these deaths occur in low- and middle-income countries, and globally falls result in more years lived with disability than transport injury, poisoning, drowning and burns combined. Falls are a growing and under-recognized public health issue and many factors – including ageing populations, increased urbanization and sedentary lifestyles – mean that global fall-related injury rates are predicted to rise drastically in the coming decades.
The view that falls are an inevitable part of life, particularly as we age, can create fatalism and complacency when it comes to how we respond to the problem. But there is growing evidence and awareness – upon which this resource is based – that many falls are preventable and that prevention efforts are effective. There is nothing to stop us strengthening these efforts with immediate effect. Fall-prevention efforts can be led and assisted by all who are affected – communities, individuals, employees, employers, institutions, health care professionals, health and social care and leisure service providers, governments, nongovernmental organizations (NGOs) and international collaborations.
In addition, the SDGs and their associated targets give us an international mandate to improve health and reduce health inequity, which aligns well with a key goal of this package: to focus fall-prevention efforts on high-risk groups in both low- and middle-income countries as well as high-income countries. Fall-prevention efforts will contribute to the achievement of three key SDGs:
• Goal 3: Ensure healthy lives and promote well-being for all at all ages
• Goal 8: Promote inclusive and sustainable economic growth, employment and decent work for all
• Goal 11: Make cities and human settlements inclusive, safe, resilient and sustainable
Now is the time to push the prevention and management of falls higher up the planning, policy, research and practice agenda and to reduce the burden of fall- related injury on a local and global scale. The World Health Organization (WHO) urges all concerned individuals to work together to implement these strategies to reduce the growing harm, suffering and loss that result from falls.
EVERY YEAR MORE THAN 684,000 PEOPLE DIE AS THE RESULT OF A FALL, AND AN ESTIMATED 172 MILLION MORE
ARE LEFT WITH SHORT- OR LONG-TERM DISABILITY – A SHOCKING STATISTIC THAT REPRESENTS SUBSTANTIAL
HUMAN SUFFERING: IN COMPARISON, 410,000 PEOPLE DIED FROM MALARIA IN 2019.
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE viii
CONTRIBUTORS
Executive editors:
David Meddings, Rebecca Ivers, Melanie Andersen Contributors:
Melanie Andersen, Soumyadeep Bhaumik, Julie Brown, Jane Elkington, Rebecca Ivers, Lisa Keay, Mei Ling Lim, Caroline Lukaszyk, Tracey Ma, David Meddings, Ha Nguyen, Madeleine Powell
The World Health Organization (WHO) would like to thank the United States Centers for Disease Control and Prevention for its financial support for the development and publication of this document.
WHO would also like to thank the following people for contributing content and expert feedback to produce this package: Shanthi Ameratunga, Elizabeth Armstrong, Clemens Becker, Jennifer Bell, Guillaume Burigusa, Ian Cameron, Kathleen Cameron, Jacqueline Close, Pham V Cuong, Ann Dellinger, Tim Driscoll, Leilei Duan, Elizabeth Eckstrom, Safa Elqsoos, Yuliang Er, Fabio Feldman, Ngochia Fidelis, Caroline Finch, Gururaj Gopalkrishna, Hongwei Hsiao, Eva Jakobson Vaagland, Wei Jiao, Sebastiana Kalula, Saija Karinkanta, Michael Keall, Denise Kendrick, Ngaire Kerse, Robin Lee, Jane McDermott, Pedro Maciel Barbosa, Mary Ann Masesar, Hanne Miang, Koen Milisen, Mary E Miller, Julie Mytton, Aleksandra Natora, Elom Otchi, Joan Ozanne-Smith, Tilman Rasche, Wim Rogmans, Vicky Scott, Cathie Sherrington, Dawn Skelton, Keith Stokes, Mohammed Tarawneh, Chris Todd, Machiko Tomita, Amita Toprani, Sebastian Van As, Henk F Van der Molen, Coen Van Gulijk, Julie Windsor, Minghui Yang, Yubin Zhao.
Other WHO staff that reviewed or provided comment on the package were Fiona Bull, Alarcos Cieza, Diana Estevez Fernandez, Zeea Han, Ivan Ivanov, Vijay Kannan, Etienne Krug, Elanie Marks, Jody-Anne Mills, Alana Officer, David Ross, Yuka Sumi, Emma Tebbutt, Jothees A Thiyagarajan, Tami Toroyan, Juana Willumsen.
Art direction and layout by Laura Salesa.com Designers: Laura Salesa, Javier Rucabado, Jezabel Escudero and Julia Gonzalez. Illustrations by Jezabel Escudero. Project coordination by Figure & Ground Communications, Dan Kent and Charlotte Shyllon.
This package was edited by Angela Burton.
ACKNOWLEDGEMENTS
ABBREVIATIONS AND ACRONYMS
KEY TERMS
SYMBOLS
UN United Nations
SDGs Sustainable Development Goals WHO World Health Organization NGOs nongovernmental organizations
NHMRC National Health and Medical Research Council
of Australia
PPE personal protective equipment
“Primary prevention” Refers to the prevention of injury
“Secondary prevention” Refers to reducing the severity of injury
“Tertiary prevention” Refers to decreasing the frequency and severity of disability after an injury
Safer people Safer environments
Safer policies and legislation
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE 1
INTRODUCTION
INTRODUCTION
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE 3
INTRODUCTION
This document, Step safely: strategies to prevent and manage falls across the life-course, is a technical package designed to support practitioners, policy- makers, managers, researchers and advocates in their work to prevent falls, and prevent and manage fall-related injuries. It describes how falls are preventable;
recommends interventions based on current evidence about what works to prevent falls; and describes how practical and policy interventions can prevent deaths and injuries across the life-course. It also provides implementation guidance on interventions for which implementation caveats feature strongly in the evidence base.
This package is structured using a life-course approach (see Box 1) and focuses on falls among three key risk groups: children and adolescents; workers; and older people.
A FALL IS AN EVENT WHICH RESULTS IN A PERSON COMING TO REST INADVERTENTLY ON THE GROUND OR FLOOR OR OTHER LOWER LEVEL. FALLS, TRIPS AND SLIPS CAN OCCUR ON ONE LEVEL OR FROM A HEIGHT (1).
Life-course approach to fall prevention BOX 1
A life-course approach to fall prevention considers the role of individual, biological, social, economic and environmental factors across the life span that can either prevent or cause falls at every age.
This approach helps identify opportunities to enable health-enhancing lifestyles and create safer environments early and at critical periods in the life-course in order to prevent falls (2).
Source: (Transforming our world: the 2030 Agenda for Sustainable Development. United Nations; 2015).
A FALL IS AN EVENT WHICH RESULTS IN A PERSON COMING TO REST INADVERTENTLY ON THE
GROUND OR FLOOR OR OTHER LOWER LEVEL. FALLS, TRIPS AND SLIPS CAN OCCUR ON ONE
LEVEL OR FROM A HEIGHT (1).
This package is for all practitioners and stakeholders working to prevent falls among those most at risk. These fall into two broad categories (between which there will be overlap):
• those working to prevent falls – from GPs to community nurses, and from parents to occupational therapists and occupational health and safety practitioners;
• those who help facilitate fall-prevention work – i.e. people who make political funding decisions, programme managers, fall-prevention advocates, architects and planners etc.
The package is also aimed at decision- and policy-makers, in particular from ministries of health; national lead agencies, where they exist (e.g. in child and adolescent safety, healthy ageing, occupational and public health etc.); and ministries of education, sport, community services, planning, product safety and finance, who can use it to generate greater political and financial engagement with fall-prevention and management.
SECTION 1: INTRODUCTION
WHO IS THIS TECHNICAL PACKAGE FOR?
Social factors
economic factors environmental factors Biological factors
Life-course approach
to fall prevention
The package also draws on a systems approach to help guide comprehensive fall- prevention planning. Such an approach involves seeing falls – their occurrence, and the severity of their outcome – as the result of the interplay of complex factors: a person’s biology (including frailty, muscle and bone strength, balance, vision and cognitive function) (3,4); their behaviour; their physical environment;
and their cultural and socioeconomic environment. A systems approach moves beyond individual behaviour and provides for environments, policies and awareness that prioritize safety, creating buffers so that falls are either avoided or made less serious because of protections in place (see Systems approach section, page 11).
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE 5
THIS TECHNICAL PACKAGE IS DESIGNED TO SUPPORT PRACTITIONERS, POLICY-MAKERS, MANAGERS, RESEARCHERS AND ADVOCATES IN THEIR WORK TO PREVENT FALLS, AND PREVENT AND MANAGE
FALL-RELATED INJURIES.
The concept, purpose and scope of this technical package were devised at a WHO Expert Consultation on Fall Prevention and Management in Geneva in June 2016. A global survey of potential end-users of the package (including 67 professionals who deal with fall prevention or management) was conducted and combined with the findings of a rapid review of evidence on what works in the prevention and management of falls. The findings of the survey and the evidence review then directly informed the development of this package.
Rapid review approach
A rapid review approach was taken to summarize the evidence about fall- prevention across three key population groups (5). This approach enabled the collation and synthesis of a large amount of evidence given the time and resources available to develop this technical package.
Evidence identification
Published research about the effect of fall-prevention interventions on fall outcomes in high-, middle- and low-income countries was sought for each key risk group: children and adolescents, workers, and older people (with separate searches conducted for older people in the community, in hospital and in residential care settings). Specific search strategies were developed for each of these population groups and these systematic literature searches were conducted in September 2017. An evidence synthesis report was developed as a standalone document, including details of search terms used, the number of records found, and the studies included (6). In addition, expert context reviewers were asked to suggest any subsequently published systematic reviews or randomized trials that contributed significant new findings to the body of evidence, and such studies were manually added.
Articles were screened for eligibility against agreed criteria to ensure that they related to the key risk groups of interest; that they included an intervention to prevent or manage falls; and that they had reported the effect of this intervention on fall outcomes. For most population groups, only the highest quality study types (systematic reviews and controlled trials) were included in the evidence synthesis report. While this approach ensured that only high-quality evidence was included, it also risked the disregarding of some useful learnings from studies with less robust designs. Thus, because the evidence base for occupational falls is less well developed than for other high-risk groups, a broader range of study types was included (including controlled before-after studies, interrupted time series studies, cohort studies, case-control studies, and crossover studies). Also, in sections where the rapid review approach used tight search criteria focused on systematic reviews and controlled trials, external expert reviewers were asked
INTRODUCTION
HOW THIS TECHNICAL
PACKAGE WAS DEVELOPED
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE 7
HOW THIS TECHNICAL PACKAGE WAS DEVELOPED
Assessment of quality and strength of evidence
As part of the evidence synthesis report (6), studies were appraised by two or more team members using standardized instruments to assess the quality and risk of bias as appropriate for each study type (7), including the AMSTAR rating tool for systematic reviews (8), Cochrane’s Risk of Bias tool for randomized controlled trials (9), the CASP Cohort Study Checklist for cohort and crossover studies (10), and criteria suggested by the Cochrane EPOC Review Group for interrupted time series and controlled before-after studies (11).
Interventions were categorized, and the overall strength of evidence for each intervention was assessed, by two or more team members using the National Health and Medical Research Council of Australia (NHMRC) Levels of Evidence guidelines (7). This is a pragmatic tool well suited for this purpose. It assesses similar domains to the Cochrane GRADE approach and includes a matrix designed for grading evidence recommendations to inform guideline development (see Annex 2). This tool was used to rate the evidence base for each intervention according to: the quality, quantity and type of available studies; the consistency of findings across studies; the extent of clinical impact, risk and benefit; the generalizability of the study population to the population of interest; and the extent of applicability to high-, low-, and middle-income settings. Because most studies were conducted in high-income settings, the rating for the applicability to low- and middle-income settings was based on a judgement of the resources (human, technology, skills etc.) required to implement the intervention. These ratings were then discussed with the full review team at an all-day workshop using a consensus approach.
SECTION 1: INTRODUCTION HOW THIS TECHNICAL
PACKAGE WAS DEVELOPED
StrenGTH DEFINITION
Interventions that were classified according to NHMRC guidelines as A, “excellent”. These interventions are consistently supported by several high-quality systematic reviews and/or randomized controlled trials and have a large benefit.
RECOMMENDED
Interventions that were classified according to NHMRC guidelines as B, “good”. These interventions are supported by evidence from some robust studies including randomized trials and systematic reviews, and have a significant benefit.
PROMISING
Interventions that were classified according to NHMRC guidelines as C, “satisfactory”. These interventions are supported by evidence from some robust studies, but there may be only few studies, or studies may have some risk of bias or conflicting evidence about the extent of the benefit of the intervention.
PRUDENT
Some interventions were classified according to NHMRC guidelines as D, which have poor or weak evidence to support their use. This package nonetheless recommends these interventions as “prudent” where they were judged by experts to be advisable despite a current lack of high-quality research to support their use, where the intervention had face validity and did not result in significant harm in reviewed studies. (It is worth mentioning that some prudent interventions may never have a body of research evidence to support their use because they are unlikely to be the subject of high-quality research studies due to difficulties in performing the required research, or because the intervention seems so basic and fundamental that research is not deemed necessary. This should not rule out these interventions as unimportant or unworthy The evidence base was robust in some areas (e.g. interventions for fall prevention among older people living at home) while in other areas it was promising at best (e.g. occupational falls). The recommendations in this technical package are as follows:
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE 9
HOW THIS TECHNICAL PACKAGE WAS DEVELOPED
Limitations of the research
It is important to note the limitations of research evidence in guiding practice.
Much safety practice is not supported by formal research trials with people, but still makes common sense according to the principles of physics and other pure sciences. For instance, there is no body of high-quality evidence to support the use of parachutes for military pilots, but most would agree it is more prudent to use one rather than not if jumping from an aircraft. That said, interventions with neither research evidence nor a strong pragmatic rationale to support their use have not been included as recommendations in the package, though some are discussed in the document where they are commonly used in practice or often described in the literature.
Package preparation and peer review
The draft evidence synthesis report was used as the basis for the development of this technical package. Each population section in the package was initially drafted by a review team member, then one team member took responsibility as the main author for subsequent drafts of the whole document to ensure consistency throughout (see Contributors). This main author then worked with a technical writer and WHO staff on iterative drafts. In February 2020 a draft was circulated by WHO to 50 external reviewers who are global experts in fall prevention and management for critical feedback. This feedback was then collated by WHO and a list of suggested changes was circulated to reviewers and incorporated into the final draft by the authorship team.
INTRODUCTION WHAT THIS TECHNICAL
PACKAGE CONTAINS AND HOW TO USE IT
Section 1: This section identifies the main risk and protective factors for each of the key at-risk risk groups targeted in this package – be it children in playgrounds, homes, schools or the outdoor environment; workers in a range of settings; or older people at home, in residential care or in hospital. It provides the context for falls and fall prevention across the three key age groups, and can help guide decisions on where to focus fall-prevention and management efforts.1
Section 2 contains a situational assessment that outlines the first steps to understanding local needs (e.g. who is most at risk, what interventions could work in your context; what resources are available), and in deciding what success will look like and how to identify when success has been achieved. This section provides an outline of the key steps involved in performing a situational assessment in any given context, in order to help focus fall-prevention and management efforts.
Section 3 provides a selection of interventions that can be implemented to address the needs identified by the situational assessment. These are labelled strongly recommended, recommended, promising, or prudent, and are presented for each of the three main life-course groups most at risk: children and adolescents, workers, and older people.
This section provides evidence on what works to prevent falls for each key risk group; suggested steps to implement interventions at local or national levels; and links to available tools, research articles and other resources. Case studies are provided throughout as examples of how fall-prevention interventions are being implemented in different settings.
Section 4: This section escribes the basic management principles that apply when falls occur, and provides links to resources and guidelines for the treatment and management of serious fall-related injuries. The conclusion summarizes the actions and contexts required to prevent and manage falls at a national and global level.
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE 11
A SYSTEMS APPROACH TO ADDRESSING FALLS
As well as being defined as strongly recommended, recommended, promising or prudent, and in addition to being tailored to the needs of children and adolescents, workers, and older people, these interventions fall broadly into the three “safe system” domains: safer people, safer environments, and safer policies and legislation (each denoted throughout this package by green symbols). While there is overlap between these domains, they broadly encompass the following:
PEOPLE
Safer people interventions aim to strengthen awareness, knowledge and skills, and access so that individuals, organizations and communities can make safer choices when it comes to preventing falls. Strengthening awareness includes making people aware of their personal vulnerability to falls (e.g. as a result of loss of muscle strength with age, or reduced vision); awareness of risk factors such as alcohol, medications or hazards in their environment; and greater awareness of evidence-based fall prevention interventions (such as exercise for older adults).
Improving access may include ensuring appropriate opportunities for lifelong physical activity that builds and maintains balance, muscle strength and bone density. Safer people interventions also include improving people’s knowledge and skills about how to perform tasks safely or to use products safely – be it a ladder, a child’s highchair or stroller – to avoid a fall.
ENVIRONMENTS
Safer environment interventions aim to eliminate fall hazards in the home, the community or in the workplace – for example, providing soft-fall surfaces that can reduce the risk of injury to children falling in playgrounds; stair guards to prevent children falling down stairs;
or scaffolding for construction workers that includes guard rails and toe boards, planked platforms, and safe access points. They also aim to create supportive active transport and mobility systems and health care facilities and improve product safety.
POLICIES
Safer policies and legislation interventions are a powerful tool for achieving behavioural or environmental change, especially when accompanied by enforcement.
These may include, for example, legislation that demands the use of safe scaffolding, harnesses or helmets; laws that require landlords to install window guards on windows in high-rise accommodation;
regulations that stipulate the use of non-slip surfaces in public buildings; or regulations that prohibit unsafe products such as baby walkers; or government policies mandating best practice guidelines for home design or minimum standards for clinical falls risk assessments.
INTRODUCTION A SYSTEMS APPROACH TO
ADDRESSING FALLS
A note on “prevention” terminology
A systems approach to reducing the negative health consequences of falls acknowledges that while we cannot prevent falls from happening all together, we are able to take steps to reduce the chance of a fall occurring and also the amount of harm a person experiences in the event of a fall. Prevention terminology may be used differently across a range of disciplines, so readers should be aware that this package uses the terms primary, secondary and tertiary prevention as defined in the general injury prevention literature, such as the WHO’s World report on violence and health (2001) and the WHO/UNICEF World report on child injury prevention (12) (see Box 2).
Primary and secondary interventions to prevent and manage injurious fallS BOX 2
“Primary prevention” Refers to the prevention of injury.
“Secondary prevention” Refers to reducing the severity of injury.
“Tertiary prevention” Refers to decreasing the frequency and severity of disability after an injury.
Physical measures, e.g.:
. Stair rails . Window guards . Scaffolding with rail guards . Toe boards
. Planked platforms . Safe access points
. Exercises to increase bone density
. Through exercise . Improved bone density . Teach children fall-technique
bone strengthening
scaffolding with rails
STRATEGIES TO PREVENT FALLS FROM OCCURING
STRATEGIES TO PREVENT or minimize injuries after a fall build internal
resilience These deflect energy away from the body (e.g., knee pads); absorb the force of the fall (e.g., soft playground surfaces).
Interventions that aim to prevent falls from occurring (primary prevention) and interventions that aim to reduce injuries at the time of a fall (secondary prevention) may overlap (see diagram below).
Interventions to reduce injuries after a fall are especially useful for situations where falls are expected (e.g. playing sports) or unpredictable (e.g. working outdoors in mixed terrain), or if the person experiences recurring falls. Sometimes several interventions may be used together. For instance, to protect children when using trampolines, preventive interventions such as supervision and equipment maintenance can be made, alongside secondary interventions such as ensuring a soft fall ground surface beneath the trampoline and that the hard frame is covered with safety padding.
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE 13
GLOBALLY, 75% OF FATAL FALLS
AMONG OLDER PEOPLE (AGED 70
YEARS AND OVER) OCCUR IN LOW-
AND MIDDLE-INCOME COUNTRIES.
FALLS: KEY FACTS
INTRODUCTION
Globally,
75% OF FATAL FALLS
among older people (aged 70 years and over) occur in low- and middle-income countries, even though only 65% of people aged 70 years and over live in low- and middle-income countries(13)
AGEING POPULATIONS
are associated with the rising number An estimated
172 MILLION
falls each year result in short- or long-term disability(14)Falls are the leading cause of injury in young children and are estimated to account for
25–56%
all child injury hospital visits(12, 15–17)The estimated number of global deaths from occupational falls was
36 000
in 2017, accounting for 12%684 000
PEOPLE DIE EACH YEAR FROM A FALL (13) GLOBALLY, MORE THAN
Falls are the world’s
2 ND LEADING CAUSE
ofunintentional injury deaths and are the main cause of morbidity for some age groups and sectors (13) Globally, over
80%
offatal falls occur in low- and middle-income countries(13)
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE 15
OF FALLS WORLDWIDE
SECTION 1:
THE MAGNITUDE
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE 17
SECTION 1:
According to the Global Health Estimates, in 2019 just over 66% more people died from falls than from malaria (13). Falls also place a significant burden on health systems, an estimated 172 million falls each year result in short- or long- term disability (14). Globally, falls are responsible for over 38 million disability- adjusted life years (DALYs) every year (18) – a figure that is rising steadily (1,18).
Globally, there was a 53% increase in the number of total deaths due to falls from 2000 to 2019, despite only a 6% increase in deaths due to all injuries combined during the same period (13). This represents an enormous financial and emotional burden for those families and communities affected – and one set to rise dramatically in the decades ahead if the problem is not comprehensively and strategically addressed.
THE MAGNITUDE OF FALLS WORLDWIDE
FALLS ARE THE WORLD’S SECOND LEADING CAUSE OF INJURY MORTALITY AND ACCOUNT
FOR OVER 684 000 DEATHS PER YEAR – OVER 80% OF WHICH OCCUR IN LOW- AND MIDDLE-
INCOME COUNTRIES (13).
THE MAGNITUDE OF F ALLS WORLDWIDE SECTION 1:
There are many factors driving the burden of falls at a global level – not least our ageing populations, as the highest rate of fall-related deaths is among people aged over 60 years (13). Another driving factor is the world’s growing population, which means the proportion of people living in urban areas and in multistorey and high-rise apartment buildings is increasing. This also results in more people working at height in the construction industry (19). High-rise apartment living places young children particularly at risk of serious falls, especially those from families recently relocated from rural areas where most dwellings are only one storey high (12).
Globalization and urbanization also result in the separation of families, and the removal of family-based support systems (20). This is a new phenomenon in many low- and middle-income countries, where residential care facilities and other formal services and supports for older people are not readily available.
Increasing numbers of older people now live at home without supportive care, which not only increases the risk of falls but can also impact the quality of life for older people following a fall injury (21). Changes in work, transport and recreation are also leading to more sedentary lifestyles which can increase risk of falls, particularly in older adults (22).
Inequality and the social determinants of fall-related injury
The risk of a fall being fatal is highest in low- and middle-income countries – a stark reminder that inequality is a key factor when it comes to falls and their impact. Just over 80% of fall-related mortality occurs in this group of countries, where poverty can compromise environmental safety and available medical and rehabilitation services (18). Global inequalities in standards of housing, occupational safety and health, and access to safe products also contribute to elevated risk of falls among those living in low-income communities. Limited surgical care and rehabilitation services available to people of low socioeconomic status compounds the burden of falls in terms of health outcomes for the majority of the world’s population.
And these countries’ large and ageing populations are not only increasing the death and disability that can result from falls, but also the burden of the costs of falls for national health systems.
Redressing these health outcome inequities is hampered by the limited data and research on many types of falls and at-risk groups, particularly in low- and middle-income countries. As with many other public health issues, policy-makers and practitioners in these countries face serious flaws in health information in general and injury surveillance in particular, as well as a significant lack of
WHY ARE FALLS A
GROWING PROBLEM?
STEP SAFELY: STRATEGIES FOR PREVENTING AND MANAGING FALLS ACROSS THE LIFE-COURSE 19
WHAT ARE THE RISKS?
The main risk factors for falls relate to people’s individual characteristics and circumstances (age, gender, physical capacity, cognitive capacity, developmental stage, socioeconomic status, culture etc.); hazards in the environment in which people live or work (e.g. trip hazards in older people’s homes, high-rise dwellings without window guards; unsafe steps, stairs and footpaths; unsafe scaffolding and inappropriate use of ladders); and lack of robust policies to effectively reduce the risk factors for falls and their consequences (e.g. lack of occupational health and safety legislation, lack of legislation compelling landlords to install window guards in high-rise blocks.Other risks, such as the influence of diet (malnutrition and obesity), a lack of safe transport options (particularly safe active transport options) and difficulty accessing health care, are particularly likely to affect people in low-resource settings (1,24–26), while sedentary lifestyles are a particular issue for those in high income countries.
WHO IS MOST AT RISK?
Three specific population groups account for the highest burden of falls and fall- related injury: older people, children and adolescents and workers in high risk occupations. Older people aged 60 and over have the highest risk of death or serious injury from falls and the risk increases with advancing age (13). Several high-risk occupations predispose workers to fall related injury (14), and among children and adolescents, infants in particular have high fall morbidity rates (13) .CHILDREN AND ADOLESCENTS
Falling is a normal part of development as children explore their (not always child-friendly) environment, learn to walk and challenge themselves. Minor falls are an important part of child development that help children develop fundamental movement skills and risk-assessment skills. Not all falls are problematic, and the aim should not be to eliminate all falls in children entirely, particularly not if this means reduced engagement in physical activity. But serious falls are problematic and children are prone to injurious falls as they are naturally curious and not always able to judge risk well.
Around the world, boys are more likely to die from falls than girls (13).
In 2019, falls were responsible for an estimated 31,818 deaths among children and adolescents aged below 15 years (13). Child fall mortality rates are up to three times higher in low- and middle-income countries than high-income countries (27), with the world’s highest fatal child fall rates estimated to occur in the low- and middle-income countries of South-East Asia (2.4 per 100 000 deaths) and the Eastern Mediterranean (1.8 per 100 000 deaths) (27).
CHILDREN &
ADOLESCENTS WORKERS OLDER PEOPLE
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FALLS IN CHILDREN ARE MORE PREVALENT IN
LOW- AND MIDDLE-INCOME COUNTRIES DUE
TO FACTORS SUCH AS INFORMAL AND POOR
QUALITY HOUSING AND PLAYING UNSUPERVISED
IN POTENTIALLY UNSAFE OUTDOOR SPACES.
Risk factors for falls in children and adolescents
Age, gender and poverty are important risk factors for falls (28). Different types of falls occur depending on the developmental phase and activities children are undertaking, and at all stages of child development, boys are more likely to fall than girls (29). There is also a strong link between socioeconomic status and childhood falls. Overcrowding, hazardous environments, single parenthood, young maternal age, low maternal education, caregiver stress and inequities in access to health care all increase the risk of falls and can also limit access to health care when falls do occur (12,30). Falls in children are more prevalent in low- and middle-income countries due to factors such as informal and poor quality housing (16) and playing unsupervised in potentially unsafe outdoor spaces such as in trees, on balconies, or near wells, ladders or edges of fields (31,32). Globally, children living in rural areas are at higher risk of most types of falls compared to children in urban areas, except falls from windows (33).
Growing populations mean our cities are not only getting bigger but also denser.
Increasingly, people, including children, live in high-rise apartments and have reduced access to green, recreational and safe open spaces. Urbanization and the expansion of high-rise residential living creates direct risks, such as falls from high-rise windows and balconies, but it also creates a lack of opportunity for lifelong participation in physical activity necessary to develop strength, balance and aerobic fitness required for good health (34). In addition, increasing use of technology means that more children are replacing participation in physical activities, sport and active recreation with more “screen time” as a source of leisure and socialization. Children who do not get enough physical activity, opportunities for safe exploration, adequate nutrition and sunlight, may not achieve peak bone density during late adolescence (making them more prone to osteoporosis in later life), and will also fail to develop the strength, balance or physical literacy to prevent falls and safely assess risk in childhood and adolescence (30,35,36).
Furthermore, a large number of children working in poor conditions, particularly in the construction industry in low- and middle-income countries, are exposed to high fall risk on a daily basis (37). These risk factors for falls present different challenges to be addressed by fall-prevention interventions for low- and middle- income countries when compared to those in high-income countries.
WHO IS MOST AT RISK?
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Where do children and adolescents fall?
In and around the home: Most falls among children and adolescents of all ages in both high-, and low-, and middle-income countries occur in the home, and home is also the location of a particularly high proportion of falls for infants and pre-school-aged children (38). Infant falls are most often the result of falling from furniture or from someone’s arms at home (38). There is a sound body of evidence demonstrating the effectiveness of home safety interventions in reducing falls risk among children (39–41).
In schools and playgrounds: Falls in playgrounds can be serious, particularly if a child experiences a head injury or a bone fracture in the growth plate area. In schools, a substantial proportion of falls also occur during physical education lessons (42,43). Sedentary children are more prone to sustaining an injury when they do engage in activity, compared to habitually active children, which suggests that developing physical fitness and aptitude in children is protective against falls (44). Physical activity should thus be promoted amongst children and steps taken to make them safer while being physically active, rather than avoiding activity as a means of reducing fall injury risk (44).
During sports, leisure and outdoor activities: Children and adolescents should be encouraged to engage in active sport and leisure pursuits as part of a healthy lifestyle even though some sporting activities introduce some risk of falls (22,34,45). While there is some evidence about reducing falls in organized sport (46), no formal research about how to reduce falls outdoors (such as into wells, or from trees, rooftops, cliffs and rock ledges, or construction sites) was found in the evidence review for this report.
In the workplace: Children engaged in domestic or paid work can suffer injuries, including falls. Hazardous child labour, i.e. work that can be dangerous to health and safety of children, is prohibited by international convention. Steps to reduce falls must include increased and sustained efforts to eliminate all forms of hazardous child labour (47).
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WHO IS MOST AT RISK?
CHILDREN &
ADOLESCENTS WORKERS OLDER PEOPLE
WORKING AGE AND ADULTS
2An estimated 317 million people suffer work-related injuries globally each year (48), and in 2017 alone, occupational injuries caused an estimated 304 000 deaths (14).
Falls are among the three most common causes of both fatal and non-fatal occupational injuries in many high-income countries (49–51). In 2017 there were an estimated 36 000 global deaths due to falls that occurred during work (14). In the United States of America (USA) in 2014, falls, slips and trips injured one in every 423 full-time workers and were responsible for the deaths of 798 workers (51). The most frequent injuries resulting from non- fatal falls are sprains, strains and tears, with an average of 12 days lost from work per fall injury in the USA (51). Comparison of occupational fall injuries between countries is difficult because of differences in injury definitions, data sources, and collection techniques (52).
However, studies that account for such differences suggest there is disparity in fall fatality rates not only between high- and low-and-middle-income countries, but also between high-income countries themselves and different jurisdictional areas within countries (53). For instance, fall fatality rates in the UK are approximately one third of those in the USA (53). This may be due to differences in reporting or in modifiable factors such as policy, enforcement and culture (53).
Data on the burden of falls in low- and middle-income countries are limited, but these countries undoubtedly face additional challenges in preventing occupational falls, including higher proportions of informal, poorly regulated labour practices and low enforcement of safety standards compared to high-income countries (54). Differences in employment opportunities, the nature of workplaces, and the degree of implementation and regulation of international occupational safety and health standards across countries also put people in low- and middle-income countries at higher risk of occupational falls (55). Redressing this requires evaluating the relevance, feasibility and applicability of selected effective fall-prevention interventions from high- income countries for low- and middle-income settings.
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Risk factors for falls in workers
Occupational activities that involve hazardous conditions, such as working at height or on slippery, cluttered, or unstable surfaces, increase the risk of falls in the workplace (1). The construction industry has the highest rate of fatal falls in high-income countries; fatal falls from a height occur at over seven times the rate of other industries (56). The vast majority of fatal falls in the construction industry occur among men, reflecting the predominance of men in the construction industry (57). Other industries in which workers are at high risk of falls include cleaning, maintenance, transport, agriculture, warehousing and material moving (51,56,58). Falls from heights are contributing significantly to death and disability in migrant workers travelling to high-income countries to work in the construction industry, for instance in the Middle East (19).
The highest rates of reported non-fatal falls in the USA occur in the health care sector and the wholesale and retail industries (58). In Canada, falls within the health care sector are most common among carers, facility support service workers and community health workers (59), with both the largest number of lost workdays and the costliest fall injuries occurring among female health sector staff (51). Older workers have a higher chance of falling in all workplaces, with those working well into older age particularly vulnerable to occupational falls.
WHO IS MOST AT RISK?
WHO IS MOST AT RISK?
A large proportion of the workforce in low- and middle-income countries is employed in the informal economy (60) where poor working conditions, irregular working hours, a lack of protection, and lack of representation often mean worker safety is overlooked (61). Informal economies often employ vulnerable workers such as children, pregnant women, older persons and migrant workers (62) – all of whom are at higher risk of injury and less likely to have access to insurance or other kinds of social benefits (63). In this context, severe fall injuries can result in permanent exclusion from the labour market and poverty, given frequently absent or inadequate workers’ compensation and social welfare (54).Where do workers fall?
Falls can occur in any workplace. In high-income countries such as the USA, falls among health care sector workers primarily occur in community settings – either outdoors, in patients’ rooms or kitchens – and are associated with slippery surfaces due to icy conditions or liquid contaminants (64). Falls on construction sites commonly occur from roofs, ladders and scaffolding, through floor openings and down stairs (65).
There seems to be little evidence relating to the location and mechanism of falls in low- and middle-income countries. However, one study shows that in these countries the commonest cause of spinal cord injury is falls from roof tops and trees while collecting fodder for animals – in rural communities many families will own animals for which fodder has to be collected regularly in this way (66) (see Case study 1).
Most evaluated occupational fall-prevention interventions target the construction, service and health care sectors. Further research is required to determine whether these interventions are relevant for other occupations where individuals are exposed to high fall risk, such as maintenance, transport and agriculture (55).
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Data collection reveals role of falls in traumatic spinal cord injurY
NEPAL
Data on falls in low- and middle-income countries is often lacking, but some countries are undertaking research to shed light on the problem.
The Spinal Injuries Rehabilitation Centre (SIRC) in Sanga, Nepal, conducted a study on patients admitted between 2015 and 2016, and has found that that falls are the country’s main cause of traumatic spinal cord injury (TSCI) – knowledge that could be used to guide future action to prevent such falls.
The SIRC study, conducted on 184 patients, revealed that falls caused almost 70% of TSCI across both genders and all age groups. Of the fall- related incidents, falls from trees (47%) were the most commonly reported, followed by falls from a building or structure (often due to unsafe buildings and a lack of safety precautions) (34%), and falls from a cliff or mountainside (10%). In Nepal, falls predominantly affect farmers and members of rural communities who climb trees to collect fruits and leaves for fodder for their livestock.
Nearly twice as many men than women were admitted to SIRC with fall- related TSCI. As a percentage of all TSCI, falls accounted for over 80% of cases in females, and (over 64%) in males. The epidemiology of fall injuries is complex and the data in this sample may be affected by factors such as differential exposure to fall risks by gender and by lower frequency of admission from rural districts further away from the SIRC.
This study demonstrates a need for injury surveillance and further research, as a better understanding of the pattern of TSCI in Nepal, and other similar low- and middle-income countries in South-East Asia, is essential in order to enable much needed progress in TSCI prevention and rehabilitation within these contexts.
Case study 1 WHO IS MOST AT RISK?
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OUR CHANCES OF BEING
INJURED OR DYING AS A RESULT
OF A FALL INCREASE WITH AGE
ACROSS THE GLOBE.
OLDER PEOPLE
Our chances of being injured or dying as a result of a fall increase with age (67) across the globe (68). Advancing age is associated with impaired balance, poorer mobility, vision and cognition, each of which can increase the risk of falls (69). Globally, a third of people aged 65 years and older fall at least once per year, with 5% of these falls resulting in a fracture (69–71).
In nursing homes, fall rates are higher, with the average fall incidence estimated to be 1.6 falls per bed per year, with almost half of residents falling more than once a year (72). The main physical consequences of falls among older people are hip fracture, other fracture, traumatic brain injury, damage to intra-thoracic and intra-abdominal organs, spinal and nerve injuries, joint distortion and dislocation, soft-tissue damage, bruises and cuts (73). The fear of falling can also have a significant impact on quality of life in older persons (74).
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ADOLESCENTS WORKERS OLDER PEOPLE
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Risk factors for falls in older age
Falls are hard to attribute to any one risk factor (see Figure 1). Fall risk factors in interact dynamically and some risk factors can change (75,76). A range of demographic, physical, psychological, medical, socioeconomic, environmental, behavioural and other risk factors affect falls risk, although older age and a history of past falls are perhaps the most important key predictors of future falls in older people (77). The risk of a fall is higher among older people with low mobility, poor balance, those who are visually impaired, cognitively impaired and those living with Parkinson’s disease, arthritis and/or depression (4,78,79).
Gender is also an important risk factor. While younger males are more likely than younger females to die from falls, fall-related death rates are roughly similar for males and females aged over 60 years (13). More than 85% of all fall-related deaths in women occur in those aged over 60 years, while just over 60% of fall-related deaths in men occur in those aged over 60 years (13). The use of medications such as antidepressants, sedatives and antihypertensives, and polypharmacy (the ongoing concurrent use of multiple medications) also increase the risk of falls (80–
83), as does the use of alcohol and other recreational drugs. In the event of falls in older persons, low body mass index and osteoporosis are risk factors for fractures (84–86).
For those in residential care, the profile of risk factors differs to that of community dwellers (79). The level of care required also makes a difference, with older people requiring low to middle levels of care more likely to fall than both those requiring a high level of care and those requiring no care (87). In fact those with the highest risk of falls are those in care settings who are able to mobilize, but require assistance (88). Moreover, globalization and urbanization often separate families and lead to the breakdown of family-based support systems (20). This is a new phenomenon in many low- and middle-income countries, where care facilities and formal support services for older people are rare or non-existent. Increasing numbers of older people now live at home without supportive care, which not only increases the risk of falls but can also impact the quality of life for older people following a fall injury (21).
There are interesting cultural differences in fall risks that are yet to be conclusively explained (68). For instance, the rate of falls among older Chinese people is lower than in other countries. Cultural expectations about physical activity throughout the life-course and in old age may play a role – in some cultures there is a belief that older people should rest and not exert themselves while others value remaining fit and active. Choice of activity type may also play a role. Racial and ethnic differences also exist within countries; for instance, Native American and African American people have higher rates of injurious falls than white Americans (89,90).
WHO IS MOST AT RISK?
- Multiple medication use - Inappropiate footwear - Excess alcohol intake - Lack of exercise
- Age, gender and race
- Chronic illnesses (e.g. Parkinson’s disease, Arthritis, Osteopororis) - Physical, cognitive and affective capacities decline
- Poor building design - Cracked or uneven sidewalks - Slippery floors and stairs - Insufficient lighting - Loose rugs
- Inadequate housing - Lack of social interactions - Lack of community resources - Low income and education levels - Limited access to health and social services
falls and
fall- related injuries
ENVIRONMENTAL RISK FACTORS
BEHAVIOURAL RISK FACTORS
BIOLOGICAL RISK FACTORS SOCIOECONOMIC
RISK FACTORS
RISK FACTOR MODEL FOR FALLS IN OLDER AGE FIGURE 1
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Where do older people fall?
In and around the home: Older people living independently in the community are most likely to fall in and near their own homes, where falls on stairs and in bathrooms are associated with high risk of injury. Trip hazards, slippery or uneven flooring, poor lighting, clutter and lack of handrails are key environmental fall risks for older people at home (91). Falls also occur away from the home, including in public spaces, on public transport and when navigating road systems as pedestrians or cyclists (92,93) and when using motorized mobility scooters (94).
In residential care facilities: Residential care facilities are domestic settings (including nursing homes and care homes) providing long-term care for people who are no longer able to care for themselves independently due to disability.
Older people often adapt poorly to new environments and once placed in residential care are more likely to fall and are more likely to experience severe consequences following a fall compared to those living in the community (87,95).
They also have impaired mobility and/or cognition that increases their falls risk.
Residents’ rooms and adjoining bathrooms are the most common places of falls in residential care, while the periods between late morning and midday, and afternoon and early evening (i.e. before meal times) are the times that falls in residential care are commonly reported (87).
Within residential care facilities, fall-related injuries are more commonly reported and studied among older people in nursing homes. Residential care for older people in low- and middle-income countries is not as readily accessible as in high-income countries, and because of traditional values, older people in low- and middle-income countries are usually reluctant to leave home to live in residential care (96).
In hospitals: Most research on fall prevention in hospitals has been conducted with older adults (97) and reveals that the key risk factors are:
• the impact of surgery or a specific diagnosis on mobility (71,98);
• delirium (99,100);
• the use of particular medications, introduction of new medications and/or other changes to existing medications (71,98,101);
• the unfamiliar and unknown environment, leading to challenges in navigation and mobility (71);
• environmental hazards such as inappropriate bed height (98);
• bed rest and lack of mobilization during hospital stay, leading to reduced mobility and function (102). For example, in 2015 it was estimated that in one of France’s largest hospitals, 20% of all patients older than 70 were significantly less able to perform the basic tasks necessary for daily living at the time of discharge than they were when they entered the hospital (103);
• lack of one-to-one patient education on reducing fall risk (104);
• inadequate training or supervision of staff, a lack of protocols or failure to implement protocols (105);
• lack of effective communication between clinical staff and patients, which can undermine opportunities for patients to request mobility assistance and report pain or medication side effects, all of which are related to fall risk (106).
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Many other risk factors for falls in hospital settings are general risk factors as well as agitation and confusion, and environmental hazards such as poor lighting, uneven flooring, trip hazards and suboptimal chair heights (79,107—111).
The availability of staff able to deal with the needs of older patients may also have an impact on falls risk (98). While many risk factors are not unique to hospital settings, they may be more commonly associated with hospitals due to their higher prevalence among hospital patients. Risk factors for falls in acute hospitals do not seem to differ from those in rehabilitation hospitals (98).
The majority of studies included in the systematic evidence review focused on older adults, and all focused on high-income countries. This lack of evidence on in-hospital fall-prevention interventions in low- and middle-income countries may be due to different practice priorities. For example, many health care services in low- and middle-income countries have historically had to focus on delivering basic service to save the lives of as many people as possible,which has often resulting in limited investment in quality improvement efforts, including patient safety (112,113).
WHO IS MOST AT RISK?
Fall prevention and management should take a systems approach, which strives to create safer people, safer environments and safer policies and legislation (see page 11) and uses targeted prevention interventions to address the risk factors.
There is growing evidence about effective interventions, particularly in high- income countries, and fall-prevention interventions have been implemented and evaluated by organizations, services, employers and researchers for many years. International partnerships and centres of research excellence now exist (for example, the Prevention of Falls Network for Dissemination ProFouND partnership, the Fall Prevention Centre of Excellence, the United States Centers for Disease Control and Prevention, USC Leonard Davis School of Gerontology);
major forums have been held; and several significant reports and many resources have been published in recent years, including the WHO global report on fall prevention in older age (68,114).
Interventions to address risk factors include improving physical mobility issues, awareness of medication use, community infrastructure and housing, public awareness, appropriate policies and legislation. Research needs to identify best practice in specific settings tailored to different income and resource settings.
While some risk factors cannot be changed (like age and sex), other factors can be modified. Interventions can be exercise-based, behavioural, cultural, educational, clinical, environmental or technological. They can be implemented as single interventions or as part of multicomponent programmes, or multifactorial programmes (these are multicomponent programmes that are tailored to address individual needs and risk-factors).
Some of the interventions in this package are “primary prevention interventions”
and are designed to prevent falls (e.g. window guards, stair rails, non-slip flooring); others are “secondary prevention interventions” and are designed to minimize the impact of a fall should it happen (e.g. soft surfacing in playgrounds, hip and back protectors, furniture corner covers, exercise to strengthen bones and muscles after a fall etc.). These interventions can be made, as appropriate, during the three key life-course stages highlighted in this technical package:
childhood and adolescence; working years; and older age. Section 2 sets out these interventions according to life-course stage with recommendations based on the strength of evidence available for each. Section 3 describes “tertiary prevention interventions” – the key aspects of fall management required to prevent death and minimize disability and suffering for those who have experienced a serious fall-related injury.
APPROACHES TO PREVENTING AND MANAGING FALLS
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